This invention relates to devices which treat tachyarrhythmias (rapid heart rhythms), and more specifically, to methods to provide delivery of atrial cardioversion and defibrillation shocks at appropriate times relative to atrial and ventricular depolarizations.
It has long been recognized that synchronizing atrial and ventricular cardioversion to depolarizations in the chamber being treated improves efficacy of treatment. For example, synchronization of ventricular cardioversion shocks to sensed R-waves is disclosed in U.S. Pat. No. 4,375,817 issued to Engle et al. Synchronization of cardioversion shocks intended to treat atrial or ventricular tachycardia or fibrillation to detected R-waves is disclosed in U.S. Pat. No. 4,384,585, issued to Zipes. Synchronization of atrial cardioversion shocks to detected P-waves is disclosed in U.S. Pat. No. 4,572,191, issued to Mirowski et al.
Delivery of cardioversion or defibrillation shocks intended to terminate a tachyarrhythmia of one chamber unfortunately may induce a tachyarrhythmia in the other chamber. The risk associated with tachyarrhythmia induction in the ventricle is sufficiently great that it has long been recognized that atrial defibrillation pulses need to be timed to avoid the vulnerable period of the ventricle. The most common approach to accomplish this result has been to deliver the atrial defibrillation or cardioversion pulse closely synchronized to a sensed ventricular depolarization to avoid the associated ventricular vulnerable period, as disclosed in U.S. Pat. No. 4,384,585, issued to Zipes. It has also long been recognized that the vulnerable period following a ventricular depolarization may extend to include the time of occurrence of the next subsequent ventricular depolarization in the presence of a sufficiently rapid ventricular rhythm. In such cases, there is no safe time for delivery of a cardioversion pulse, as discussed in the article xe2x80x9cSynchronous Intracardiac Cardioversionxe2x80x9d, by Zipes et al., published in Modern Cardiac Pacing, edited by Barold, Futura Publishing Co. 1985, pages 727-743.
Because cardioversion pulses synchronized to a ventricular rhythm which is too rapid may induce ventricular arrhythmias or fibrillation, implantable cardioverters have typically included some method to assure that a minimum R-R interval has elapsed as a prerequisite to delivery of a cardioversion shock. One such synchronization method which prevents delivery of a cardioversion pulse synchronized to a ventricular rhythm which is too rapid is to require that the shock be synchronized to a ventricular depolarization falling outside a defined refractory period defined following the immediately preceding ventricular depolarization, as in the Model 7210 implantable transvenous cardioverter manufactured by Medtronic, Inc. While this device could sense ventricular depolarizations during this refractory period and would initiate a new refractory period following such depolarizations, it would not deliver cardioversion pulses synchronized to such depolarizations. As reflected in the above-cited article by Zipes et al, the transvenous cardioversion therapy provided by the model 7210 device could be employed to treat either ventricular or supraventricular tachyarrhythmias.
A more sophisticated method of synchronization to sensed R-waves is set forth in U.S. Pat. No. 5,486,198, in which a shock is delivered synchronized to an R-wave only if the R-R interval between the R-wave and the immediately preceding R-wave is greater than or no more than a defined amount less than the immediately preceding R-R interval. This method of synchronization to sensed R-waves, like those discussed above, unfortunately does not allow safe delivery of an atrial cardioversion shock in the presence of too rapid a ventricular rate.
An alternative method for preventing delivery of an atrial cardioversion shock during the ventricular vulnerable period is to deliver the shock after a defined interval following a preceding R-wave, in the absence of an intervening sensed ventricular depolarization, the defined interval being sufficiently long to prevent delivery during the vulnerable period associated with the preceding R-wave. Such a synchronization method is disclosed in U.S. Pat. No. 5,411,524, issued to Mehra. As disclosed in the Mehra patent, the defined interval may vary as a function of the sensed ventricular rate, but it must be greater than a predefined minimum duration and thus is also unavailable in the presence of too rapid a ventricular rate.
An additional method for avoiding delivery of a cardioversion pulse during the vulnerable period of a chamber of the heart is to pace the chamber and deliver the cardioversion pulse in the refractory period following the pacing pulse. One such approach is also disclosed in U.S. Pat. No. 5,411,524 issued to Mehra, wherein an atrial cardioversion pulse is synchronized to a single ventricular pacing pulse and in U.S. Pat. No. 5,193,536, also issued to Mehra, wherein a ventricular cardioversion pulse is synchronized to the last of a series of ventricular pacing pulses. In both cases, the ventricular pacing pulse escape interval is calculated to be less than the intervals separating intrinsic ventricular depolarizations. These methods, unfortunately are not necessarily useful in the case of a ventricular rhythm so rapid that synchronization to is an overdrive ventricular pacing pulse is unsafe.
The present invention provides an implantable atrial defibrillator which provides for safe delivery of atrial cardioversion pulses even in the presence of a ventricular rate so rapid it would otherwise preclude safe atrial cardioversion. The device takes advantage of the phenomenon similar to one observed in bradycardia pacing, turning it to a new use in the context of an atrial cardioversion synchronization method. In bradycardia pacing it has been observed that delivery of a an overdrive ventricular pacing pulse closely timed to a sensed R-wave causes a prolonged R-R interval thereafter, much like the compensatory pause following a PVC. It has been determined by the inventor that this phenomenon manifests itself even in the presence of atrial fibrillation. This fact in turn has allowed the development of an atrial cardioversion synchronization method which allows safe delivery of atrial cardioversion pulses in the presence of very rapid ventricular rates.
A device employing the method of the present invention measures the intervals separating R-waves in the presence of atrial fibrillation and calculates a shorter ventricular pacing escape interval, similar to the method described in the above-cited Mehra ""524 patent, on expiration of which a ventricular pacing pulse is delivered. However, rather than delivering an atrial cardioversion pulse synchronized to the delivered ventricular pacing pulse, the device relies upon the expected extended intrinsic R-R interval following the delivered pacing pulse and defines a synchronization interval following the delivered pacing pulse which is longer than the previous ventricular pacing escape interval, and which may also be longer than the previous intrinsic R-R intervals. The device delivers an atrial cardioversion pulse thereafter on occurrence of the next sensed R-wave, provided it occurs after expiration of the synchronization interval. In some embodiments of the invention the device may deliver a cardioversion pulse alone or in conjunction with a delivered ventricular pacing pulse on expiration of a lower rate interval longer than the synchronization interval, in the absence of a sensed R-wave.
The inventive synchronization method, although similar in some respects to each of the synchronization methods described above, provides a result unobtainable with any of the above described methods. Because the overdrive ventricular pacing pulse need not trigger an R-wave which itself may be safely employed for synchronized delivery of an atrial cardioversion pulse, it may be delivered in circumstances where the synchronization method of the Mehra ""524 patent could not be safely employed. Because the delivered overdrive ventricular pacing pulse triggers an increased intrinsic R-R interval, a relatively long synchronization interval can be employed to allow safe delivery of atrial cardioversion pulses even in the presence of a ventricular rate which normally would be too rapid to allow for safe delivery of synchronized atrial cardioversion.